Prevention and Prevention and Mental Health Mental Health

PromotionPromotion

Prevention and mental health Prevention and mental health promotion are important parts of promotion are important parts of psychiatric care. The mere absence psychiatric care. The mere absence of mental illness does not mean that of mental illness does not mean that one has positive mental health or a one has positive mental health or a high quality of life. In the objectives high quality of life. In the objectives of of Healthy People 2010Healthy People 2010 (USDHHS, (USDHHS, 2000, p 37), mental health is defined 2000, p 37), mental health is defined in a positive way: in a positive way:

Mental health is sometimes thought of as Mental health is sometimes thought of as simply the absence of a mental illness but it simply the absence of a mental illness but it is actually much broader. Mental health is a is actually much broader. Mental health is a state of successful mental functioning, state of successful mental functioning, resulting in productive activities, fulfilling resulting in productive activities, fulfilling relationships, and the ability to adapt to relationships, and the ability to adapt to change and cope with adversity. Mental change and cope with adversity. Mental health is indispensable to personal health is indispensable to personal wellbeing, family and interpersonal wellbeing, family and interpersonal relationships, and one's contribution to relationships, and one's contribution to society society

Models of Primary Models of Primary PreventionPrevention : :

Primary prevention is often Primary prevention is often described with slogans such as "An described with slogans such as "An ounce of prevention is worth a ounce of prevention is worth a pound of cute". However, the major pound of cute". However, the major emphasis in the United States has emphasis in the United States has been on secondary prevention been on secondary prevention activities or the treatment of mental activities or the treatment of mental disorders. disorders.

Mental health promotion has largely Mental health promotion has largely been ignored within the nursing been ignored within the nursing profession (Scannell-Desch, 2005; profession (Scannell-Desch, 2005; Calloway, 2007). Only recently is Calloway, 2007). Only recently is primary prevention emerging as a primary prevention emerging as a substantial force in the mental substantial force in the mental health movement. health movement.

Thus primary prevention activities Thus primary prevention activities in psychiatric care have two basic in psychiatric care have two basic aimsaims::

To help people avoid stressors or To help people avoid stressors or cope with them more adaptively. cope with them more adaptively.

To change the resources, policies, or To change the resources, policies, or agents of the environment so that agents of the environment so that they no longer cause stress but they no longer cause stress but rather enhance people's functioning. rather enhance people's functioning.

Health promotion and illness Health promotion and illness prevention activities are derived prevention activities are derived from a public health model of care. from a public health model of care. This model is intrinsic to nursing but This model is intrinsic to nursing but distinct from the medical model. distinct from the medical model. Differences emerge when comparing Differences emerge when comparing these two models. these two models.

Public Health Prevention Public Health Prevention ModelModel : :

In the public health prevention In the public health prevention model model the "patient" is communitythe "patient" is community rather than the individual, and the rather than the individual, and the focus is on the amount of mental focus is on the amount of mental health or illness in the community as health or illness in the community as a whole, including factors that a whole, including factors that promote or inhibit mental health. promote or inhibit mental health.

The emphasis in the public health model The emphasis in the public health model is on reducing the risk of mental illness is on reducing the risk of mental illness for rand entire population by providing for rand entire population by providing services to high-risk groups.services to high-risk groups.

Use of the public health model requires that Use of the public health model requires that mental health professional be familiar with mental health professional be familiar with skills such as community needs assessment, skills such as community needs assessment, identifying and prioritizing target or high-risk identifying and prioritizing target or high-risk groups, and intervening with treatment groups, and intervening with treatment modalities such as consultation, education, modalities such as consultation, education, and crisis intervention. and crisis intervention.

Community Needs AssessmentCommunity Needs Assessment : :

In the public health model services In the public health model services are developed and delivered based are developed and delivered based on a culturally sensitive assessment on a culturally sensitive assessment of community needs. Because it is of community needs. Because it is not possible to interview each not possible to interview each person in the community to person in the community to determine mental health needs, four determine mental health needs, four techniques are used to estimate techniques are used to estimate service needs service needs

Social indicators:Social indicators: examples of statistics most examples of statistics most commonly used are income, race, marital status, commonly used are income, race, marital status, population density, crime, and substance abuse. population density, crime, and substance abuse.

Key informants:Key informants: are people knowledgeable are people knowledgeable about the community's needs. about the community's needs.

Community forums:Community forums: invite members of the invite members of the community to aeries of public meetings where community to aeries of public meetings where they can express their ideas and beliefs about they can express their ideas and beliefs about mental health needs in their community. mental health needs in their community.

Epidemiological studies:Epidemiological studies: examine the examine the incidence and prevalence of mental disorders in incidence and prevalence of mental disorders in a defined population a defined population

Identifying and Prioritizing High-Identifying and Prioritizing High-Risk GroupsRisk Groups::

When the data from the various When the data from the various community needs assessments are community needs assessments are analyzed, specific high-risk groups analyzed, specific high-risk groups begin to emerge. For example, begin to emerge. For example, elderly widows live in the elderly widows live in the community.community.

Community mental health providers Community mental health providers might consider adolescents in this might consider adolescents in this community to be at risk for mental community to be at risk for mental health problems and target them for health problems and target them for intervention intervention

InterventionIntervention : :

The public health model applies The public health model applies three levels of preventive three levels of preventive intervention to mental illness and intervention to mental illness and emotional disturbance (Caplan, emotional disturbance (Caplan, 1964): 1964):

Primary prevention: Primary prevention: is lowering the is lowering the incidence of a mental disorder by incidence of a mental disorder by reducing the rate at which new reducing the rate at which new cases of a disorder develop. cases of a disorder develop.

Secondary prevention: Secondary prevention: involves involves decreasing the prevalence of a mental decreasing the prevalence of a mental disorder by reducing the number of disorder by reducing the number of existing cases through early case existing cases through early case finding, screening, and prompt, effective finding, screening, and prompt, effective treatment. treatment.

Tertiary prevention: Tertiary prevention: attempts to reduce attempts to reduce the severity of a mental disorder and its the severity of a mental disorder and its associated disability through associated disability through rehabilitative activities. rehabilitative activities.

Each of these levels of intervention Each of these levels of intervention has implications for psychiatric has implications for psychiatric nursing practice. nursing practice. Primary Primary prevention prevention is the focus of this is the focus of this chapter. chapter. Secondary preventionSecondary prevention is is addressed in Chapter 13, "Crisis addressed in Chapter 13, "Crisis Intervention." Intervention." Tertiary prevention is Tertiary prevention is described described in Chapter 14, "Recovery in Chapter 14, "Recovery and Psychiatric Rehabilitation." and Psychiatric Rehabilitation."

Medical Prevention ModelMedical Prevention Model : :

The medical prevention model The medical prevention model focuses on biological and brain focuses on biological and brain research to discover the specific research to discover the specific causes of mental illness, with causes of mental illness, with primary prevention activities primary prevention activities focused on the prevention of illness focused on the prevention of illness in the in the individual patient. individual patient. This This model consists of the following model consists of the following steps: steps:

1.1. Identify a Identify a disease disease that warrants the that warrants the development of a preventive intervention development of a preventive intervention program. Develop reliable methods for its program. Develop reliable methods for its diagnosis diagnosis so that people can divided series so that people can divided series of epidemiological and laboratory studies, of epidemiological and laboratory studies, identify the likely identify the likely cause cause of the disease. of the disease.

2.2. Launch and into groups according to Launch and into groups according to whether they do or do not have the disease. whether they do or do not have the disease.

3.3. By a revaluate and experimental preventive By a revaluate and experimental preventive intervention program based on the results intervention program based on the results of those studies. of those studies.

Nursing Prevention ModelNursing Prevention Model : :

The nursing prevention model The nursing prevention model stresses the importance of stresses the importance of promoting mental health and promoting mental health and preventing mental illness by focusing preventing mental illness by focusing on risk factors, protective factors, on risk factors, protective factors, vulnerability, and human responses. vulnerability, and human responses.

In the nursing prevention model, In the nursing prevention model, the "patient" may be and the "patient" may be and individual, family, or community.individual, family, or community.

It is based on the understanding that It is based on the understanding that mental disorders are the result of mental disorders are the result of many causes, requiring that mental many causes, requiring that mental illness prevention be thought of in a illness prevention be thought of in a more behavioral way as the more behavioral way as the promotion of adaptive coping promotion of adaptive coping responses and the prevention of responses and the prevention of maladaptive responses to life maladaptive responses to life stressors. stressors.

Stressors can include single-episode Stressors can include single-episode events, such as a divorce, or long-events, such as a divorce, or long-standing conditions, such as marital standing conditions, such as marital conflict. They can reflect either an conflict. They can reflect either an acute health problem or a chronic acute health problem or a chronic health problem. health problem.

The nursing prevention model The nursing prevention model thus assumes that problems are thus assumes that problems are multicausal, that everyone is multicausal, that everyone is vulnerable to stressful life vulnerable to stressful life events, and that any disability or events, and that any disability or problem may arise as a problem may arise as a consequence.consequence.

For example: four For example: four vulnerable people vulnerable people can face a stressfulcan face a stressful life event, such as life event, such as the ending of a marriage or the loss of a the ending of a marriage or the loss of a job.job.

One person may become severely One person may become severely depressed, the second may be involved depressed, the second may be involved in an automobile accident, the third in an automobile accident, the third may begin to drink heavily, and the may begin to drink heavily, and the fourth may develop coronary artery fourth may develop coronary artery disease. disease.

The nursing prevention model does The nursing prevention model does not search for a cause of each not search for a cause of each problem. Rather, I involves the problem. Rather, I involves the following steps: following steps:

1.1. Identifying a Identifying a stressorstressor that appears to that appears to result in a result in a maladaptive coping maladaptive coping responseresponse in a significant portion of in a significant portion of the population. Develop procedures the population. Develop procedures for reliably identifying people who are for reliably identifying people who are at riskat risk for the stressor and for the stressor and maladaptive response. maladaptive response.

1.1. By epidemiological and laboratory By epidemiological and laboratory methods, study the consequences of methods, study the consequences of that stressor and develop hypotheses that stressor and develop hypotheses related to how its negative related to how its negative consequences might be reduced or consequences might be reduced or eliminated. eliminated.

2.2. Launch and evaluate an Launch and evaluate an experimental preventive intervention experimental preventive intervention program based on these hypotheses. program based on these hypotheses.

The nursing model also includes The nursing model also includes application of the nursing process, application of the nursing process, focusing on the primary prevention focusing on the primary prevention of maladaptive coping responses of maladaptive coping responses associated with an identified associated with an identified stressor. It thus incorporates the stressor. It thus incorporates the following aspects: following aspects:

Assessment:Assessment: identifying a stressor that precipitates identifying a stressor that precipitates maladaptive responses and a target or population maladaptive responses and a target or population group that is vulnerable or at risk for it. group that is vulnerable or at risk for it.

Planning:Planning: formulating specific prevention strategies formulating specific prevention strategies and social institutions and situations through which and social institutions and situations through which the strategies may be applied. the strategies may be applied.

Implementation:Implementation: applying selected nursing applying selected nursing interventions aimed at decreasing maladaptive interventions aimed at decreasing maladaptive responses to the identified stressor and enhancing responses to the identified stressor and enhancing adaptation. adaptation.

Evaluation:Evaluation: determining the effectiveness of the determining the effectiveness of the nursing interventions with regards to short-and long-nursing interventions with regards to short-and long-term outcomes, use of resources, and comparison term outcomes, use of resources, and comparison with other prevention strategies. with other prevention strategies.

AssessmentAssessment

Risk Factors and Protective Risk Factors and Protective Factors. Factors.

Target Populations.Target Populations.

Planning and Planning and ImplementationImplementation::

Health educationHealth education Environmental changeEnvironmental change Social supportSocial support Stigma reductionStigma reduction

Stigma ReductionStigma Reduction : :

An important aspect of mental health An important aspect of mental health promotion involves activities related to promotion involves activities related to dispelling myths and stereotypes dispelling myths and stereotypes associated with vulnerable groups, associated with vulnerable groups, providing knowledge of normal providing knowledge of normal parameters, increasing sensitivity to parameters, increasing sensitivity to psychosocial factors affecting health and psychosocial factors affecting health and illness, and enhancing the ability to give illness, and enhancing the ability to give sensitive, supportive, and humanistic sensitive, supportive, and humanistic health care. health care.

Stigma is defined as "a cluster of Stigma is defined as "a cluster of negative attitudes and beliefs that negative attitudes and beliefs that motivate the general public to fear, motivate the general public to fear, reject, avoid, and discriminate reject, avoid, and discriminate against people with mental illness." against people with mental illness."

For the psychiatrically ill, stigma is a For the psychiatrically ill, stigma is a barrier that separates them from society barrier that separates them from society and keeps them apart form others (Box and keeps them apart form others (Box 12-5). They are the result, in part, of the 12-5). They are the result, in part, of the cultural stigma against mental illness cultural stigma against mental illness that is prevalent in contemporary that is prevalent in contemporary society. For example, one study found society. For example, one study found that 39% of all newspaper stories that 39% of all newspaper stories related to mental illness focused on related to mental illness focused on dangerousness and violence. dangerousness and violence.

The impact of this stigma is enormous. The impact of this stigma is enormous. Nearly two thirds of people with Nearly two thirds of people with diagnosable mental disorders do not seek diagnosable mental disorders do not seek treatment, and stigma related to mental treatment, and stigma related to mental illness is one of the major barriers that illness is one of the major barriers that discourages people from seeking needed discourages people from seeking needed care. Another sign of stigma is evident in care. Another sign of stigma is evident in the public's reluctance to pay for mental the public's reluctance to pay for mental health services and to provide the same health services and to provide the same coverage for physical and mental health coverage for physical and mental health care (Chapter 8). care (Chapter 8).

Patients and their families often Patients and their families often report that the diagnosis of a mental report that the diagnosis of a mental illness is followed by increasing illness is followed by increasing isolation and loneliness as family isolation and loneliness as family and friends withdraw. (Chapter 10). and friends withdraw. (Chapter 10).

Patients feel rejected and feared by Patients feel rejected and feared by others, and their families are met by others, and their families are met by blame. Stigma against mental illness blame. Stigma against mental illness is a reflection of the cultural biases is a reflection of the cultural biases of contemporary society that are of contemporary society that are shared by consumers and health shared by consumers and health care providers alike (Box 12-6). care providers alike (Box 12-6).

The health repercussions of The health repercussions of stigma are as followsstigma are as follows::

Stigma leads to concealment or denial Stigma leads to concealment or denial of symptoms. of symptoms.

Stigma discourages adherence to Stigma discourages adherence to effective treatments.effective treatments.

Stigma isolates the individual an Stigma isolates the individual an family.family.

Stigma inaccurately affects patients' Stigma inaccurately affects patients' beliefs about what is wrong with their beliefs about what is wrong with their health.health.

Stigma lowers self-esteem and negatively Stigma lowers self-esteem and negatively affects self-perception and self-care. affects self-perception and self-care.

Stigma limits access to quality health care. Stigma limits access to quality health care. Stigma leads to less desirable treatment Stigma leads to less desirable treatment

settings.settings. Stigma negatively affect the attitudes of health Stigma negatively affect the attitudes of health

care providers. care providers. Stigma contributes to the economic conditions Stigma contributes to the economic conditions

that influence poor outcomes. that influence poor outcomes. Stigma limits the community's response to Stigma limits the community's response to

illness.illness. Stigma limits the formation of nonprofit Stigma limits the formation of nonprofit

groups and discoveries groups and discoveries

Unlike physical illness, which tends Unlike physical illness, which tends to evoke sympathy and the desire to to evoke sympathy and the desire to help, mental disorders tend to help, mental disorders tend to disturb people and keep away. disturb people and keep away.

Yet stigma must be overcome, and Yet stigma must be overcome, and progress is being make. A recent study progress is being make. A recent study found that seeking mental health found that seeking mental health treatment has become more acceptable treatment has become more acceptable over the past decade, and perceived over the past decade, and perceived stigma associated with it h as declined stigma associated with it h as declined (Mojabai, 2007). These changes in public (Mojabai, 2007). These changes in public attitudes have likely contributed to the attitudes have likely contributed to the growing demand for mental health growing demand for mental health services in the United States and will services in the United States and will continue to do so in the coming years. continue to do so in the coming years.

Reducing stigma must involve Reducing stigma must involve programs of public advocacy, public programs of public advocacy, public education on mental health issues, education on mental health issues, and contact with persons with and contact with persons with mental illness through schools and mental illness through schools and other social institutions. Another other social institutions. Another way to reduce stigma is to find way to reduce stigma is to find causes. causes.

Finally, it must be understood that Finally, it must be understood that everyone encounters stress and that everyone encounters stress and that all people are subject to maladaptive all people are subject to maladaptive coping responses. Mental health coping responses. Mental health professional can educate the public professional can educate the public and teach them that mental health is and teach them that mental health is a continuum and mental illness is a continuum and mental illness is caused by a complex combination of caused by a complex combination of factors. factors.

Consumers need to understand Consumers need to understand that no one is immune to mental that no one is immune to mental illness or emotional problems illness or emotional problems and that the fear, anxiety, and and that the fear, anxiety, and anger we feel about people who anger we feel about people who experience these problems may experience these problems may reflect some of our own deepest reflect some of our own deepest fears and anxieties.fears and anxieties.